Local interventions for actinic keratosis in organ transplant recipients: a systematic review.

BACKGROUND: Actinic keratosis (AK) in organ transplant recipients (OTRs) has a high risk of progressing to invasive squamous cell carcinoma of the skin. Thus, early and consequent treatment of AKs is warranted in OTRs. OBJECTIVES: To summarize the current evidence for nonsystemic treatments of AKs in OTRs. METHODS: We performed a systematic literature search in MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) and hand-searched pertinent trial registers up to 22 August 2018. Randomized controlled trials (RCTs) evaluating nonsystemic interventions for AKs in OTRs were included. The risk of bias was estimated using the Cochrane Risk of Bias Tool. RESULTS: Of 663 records initially identified, eight RCTs with 242 OTRs were included in a qualitative synthesis. Most studies evaluated methyl aminolaevulinate photodynamic therapy (MAL-PDT), followed by ablative fractional laser (AFXL) and diclofenac sodium 3% in hyaluronic acid, imiquimod 5% cream and 5-fluorouracil 5% cream (5-FU). MAL-PDT showed the highest rates of participant complete clearance (40-76·4%), followed by imiquimod (27·5-62·1%), diclofenac (41%) and 5-FU (11%). Similar results were observed for lesion-specific clearance rates. Treatment with AFXL alone revealed low lesion clearance (5-31%). Local skin reactions were most intense in participants treated with a combination of AFXL and daylight MAL-PDT. There were no therapy-related transplant rejections or worsening of graft function in any trial. The overall risk of bias was high. CONCLUSIONS: Limited evidence is available for the treatment of AKs in OTRs. MAL-PDT is currently the best-studied intervention. Lesion-specific regimens may not be sufficient to achieve disease control. Field-directed regimens are preferable in this high-risk population.

[General principles of wound management in emergency departments]. / Grundlegende Techniken des Wundverschlusses in der Notaufnahme.

Wound management is one of the major tasks in emergency departments. The surrounding intact skin but not the wound itself should be disinfected before starting definitive wound treatment. Hair should first be removed by clipping to 1-2 mm above the skin with scissors or clippers as shaving the area with a razor damages the hair follicles and increases the risk of wound infections. Administration of local anesthetics should be performed directly through the exposed edges of the wound. After wound examination, irrigation is performed with Ringer's solution, normal saline or distilled water. The next step is débridement of contaminated and devitalized tissue. There are several wound closure techniques available, including adhesive tapes, staples, tissue adhesives and numerous forms of sutures. Management of specific wounds requires particular strategies. A bleeding control problem frequently occurs with scalp lacerations. Superficial scalp lacerations can be closed by alternative wound closure methods, for example by twisting and fixing hair and the use of tissue adhesives, i.e. hair apposition technique (HAT). For strongly bleeding lacerations of the scalp, the epicranial aponeurosis should be incorporated into the hemostasis. Aftercare varies depending on both the characteristics of the wound and those of the patient and includes adequate analgesia as well as minimizing the risk of infection. Sufficient wound aftercare starts with the treating physician informing the patient about the course of events, potential complications and providing relevant instructions.

Association between volume of severely injured patients and mortality in German trauma hospitals.

BACKGROUND: The issue of patient volume related to trauma outcomes is still under debate. This study aimed to investigate the relationship between number of severely injured patients treated and mortality in German trauma hospitals. METHODS: This was a retrospective analysis of the TraumaRegister DGU® (2009-2013). The inclusion criteria were patients in Germany with a severe trauma injury (defined as Injury Severity Score (ISS) of at least 16), and with data available for calculation of Revised Injury Severity Classification (RISC) II score. Patients transferred early were excluded. Outcome analysis (observed versus expected mortality obtained by RISC-II score) was performed by logistic regression. RESULTS: A total of 39,289 patients were included. Mean(s.d.) age was 49.9(21.8) years, 27,824 (71.3 per cent) were male, mean(s.d.) ISS was 27.2(11.6) and 10,826 (29.2 per cent) had a Glasgow Coma Scale score below 8. Of 587 hospitals, 98 were level I, 235 level II and 254 level III trauma centres. There was no significant difference between observed and expected mortality in volume subgroups with 40-59, 60-79 or 80-99 patients treated per year. In the subgroups with 1-19 and 20-39 patients per year, the observed mortality was significantly greater than the predicted mortality (P < 0.050). High-volume hospitals had an absolute difference between observed and predicted mortality, suggesting a survival benefit of about 1 per cent compared with low-volume hospitals. Adjusted logistic regression analysis (including hospital level) identified patient volume as an independent positive predictor of survival (odds ratio 1.001 per patient per year; P = 0.038). CONCLUSION: The hospital volume of severely injured patients was identified as an independent predictor of survival. A clear cut-off value for volume could not be established, but at least 40 patients per year per hospital appeared beneficial for survival.

Use of a carotid artery for arterial cannulation: side-related differences.

BACKGROUND: Cannulation of arch arteries (innominate, axillary or carotid) for arterial return during cardiopulmonary bypass is increasingly being used; however, the flow and pressure profile in the cannulated arteries remains unclear. The aim of this study was to evaluate the flow and pressure characteristics of arterial inflow through a carotid artery, especially with regard to operative and technical aspects, clinical outcomes, and side-related differences. METHODS: Between January 2005 and April 2008, 200 consecutive patients underwent elective aortic arch surgery at our facility. One hundred patients were assigned to undergo cannulation of the left and another 100 to undergo cannulation of the right carotid artery. Both groups were similar in terms of age, sex, and type of surgery. In all patients, arterial return was through a side-graft anastomosed to the carotid artery. The arterial line was also used for unilateral cerebral perfusion for brain protection during mild hypothermic circulatory arrest. The flow and pressure profiles in the arterial line and in the carotid artery were evaluated with regard to cardiopulmonary bypass flow rate and side of cannulation. RESULTS: No complications related to the cannulation of a carotid artery were observed. The arterial return was adequate in all patients, regardless of the side being cannulated. Because of low resistance (mean pressure<50 mmHg) in the carotid artery proximal to the inflow side-graft, the flow toward the aortic arch averaged 87+/-2% (range 84.4-92%) of the total flow volume (4.6+/-0.5 L/min), without a significant difference between the sides. However, the perfusion pressure in the arterial line was significantly higher when the left carotid artery was cannulated (216+/-30 mmHg vs. 205+/-30 mmHg; P=0.013). There was also a significant difference in the pressure in the distal carotid arteries, which, compared to the systolic blood pressure prior to cardiopulmonary bypass, increased by 30+/-24 mmHg on the left and decreased by 16+/-21 mmHg on the right (P<0.001). CONCLUSIONS: Both common carotid arteries are suitable for arterial cannulation; however, left-sided cannulation is associated with an increase in the pressure profile. Therefore, if vascular pathology does not dictate cannulation of the left carotid artery, the right carotid artery should be considered the site of choice.

New concept for the development of a confocal endomicroscope.

It is one of modern medicine's top priorities to reduce the stress for the patient during diagnosis and therapy by designing minimally invasive applications of medical techniques. Microsystems technology has always held the key to minimally invasive solutions in surgery and micro-endoscopy. The new measuring system KOMED is currently developed for the application of in-vivo cellular microscopy. This approach is based on the concept of a miniaturised fibre-optical confocal microscope. The application range of this microsensor system includes the minimally invasive optical biopsy for purposes such as the early detection of tumour cells. In this paper the concept of the KOMED system is described, as well as technical challenges to be solved in the project.

Aortic root replacement versus aortic valve replacement: a case-match study.

BACKGROUND: There is increasing evidence that patients with aortic valve disease and dilatation of the ascending aorta are at risk for later dissection or rupture of the aortic wall when the dilated ascending aorta is not replaced or reinforced at the time of aortic valve replacement. In order to find out whether the more complex surgical procedure of aortic root replacement carries a higher early or late postoperative risk than isolated aortic valve replacement, we conducted a matched-pair study with patients of both groups. METHODS: Between June 1993 and August 1998, 100 consecutive patients with aortic valve disease and ectasia/aneurysm of the ascending aorta underwent replacement of the aortic valve and the ascending aorta with a CarboSeal composite graft (CarboSeal; Sulzer Carbo-Medics Inc, Austin, TX). Identical bileaflet valve prostheses (CarboMedics; Sulzer CarboMedics Inc, Austin, TX) were implanted during the same time period in 928 patients for aortic valve disease. On the basis of various preoperative clinical variables 100 patients with aortic valve replacement were matched to the 100 patients with replacement of the aortic root. The duration of follow-up for both groups was similar with 37 + 17 months (range, 9 to 70) for the CarboSeal group and 38 + 14 months (range, 13 to 65) for the CarboMedics group. Survival and morbidity were calculated by Kaplan-Meier analysis and risk-adjusted mortality was evaluated by multivariate analysis in a Cox regression model. RESULTS: The early postoperative mortality of 1% in the CarboSeal group and 4% in the CarboMedics group was insignificantly different. Although the overall survival rate at 5 years was lower (60.7% vs 86.3%; p = 0.13) in the CarboSeal group, the freedom from cardiac mortality and valve-related morbidity was similar in the two groups. CONCLUSIONS: Replacement of the ascending aorta and aortic valve can be performed with similar operative risk, valve-related morbidity, and late cardiac mortality as isolated aortic valve replacement.

Further observations on the doubling time of human chorionic gonadotropin in early asymptomatic pregnancies.

The doubling time (DT) of human chorionic gonadotropin (hCG) in serum was investigated retrospectively using serial serum hCG values that had been obtained from asymptomatic pregnant women with a prior history of infertility. The DT of hCG did not increase significantly as pregnancy advanced during the period in gestation when the serum hCG concentration was less than 10,000 mIU/mL (International Reference Preparation). Serum hCG concentrations increased subnormally in 2 of 60 women with normal intrauterine pregnancies, 5 of 8 women with asymptomatic ectopic pregnancies (EPs), and in 2 of 8 asymptomatic women who subsequently aborted their pregnancies. Neither the sensitivity nor the specificity of serial hCG testing for EP was enhanced by adopting different test criteria at different serum hCG concentrations.

Stabilisation of human interferon beta synthesis in Escherichia coli by zinc ions.

Human interferon beta synthesized in Escherichia coli is unstable and toxic for the bacterial cell. Zinc ions are able to stabilise interferon beta in E. coli probably by inhibiting the action of cell internal proteinase(s) which affect the half-life of this foreign protein. As a result up to one order of magnitude more active IFN-beta can be detected in Zn2+-treated E. coli cells.